Cycling: Why "Bipolar" is Totally Misleading and Other Things You Need to Know

I've spent the last several weeks working on the first of what will be a series of books on bipolar. The opening book focuses on moods. The central theme is that we need to consider our illness as recurrent and cyclic rather than episodic and polar.

Goodwin and Jamison in their second edition of Manic-Depressive Illness note that our current mindset encourages clinicians to think of each depression and mania as isolated incidents rather than as part of a coherent whole. As a result, they fail to see the illness for the episode.

Way back in 1851, the French psychiatrist Jean-Pierre Falret came up with "la folie circulaire" (circular insanity) to explain the continuous pattern of depression, mania, and "normal" that he observed in his patients.

In 1915, the pioneering German diagnostician Emil Kraepelin wrote: "The course of manic-depressive insanity is marked by a recurrence of attacks separated by lucid intervals." The 1921 English translation to his classic Manic-DepressiveInsanity describes the illness as including "the whole domain of so-called periodic and circular insanity."

What we call bipolar is an enormously complex condition, but strip it to its most essential element and what we're left with can be best described as a "cycling illness." Simply knowing that we have ups and downs is not sufficient. What we need to know is how these ups and downs relate, what is driving them, and what else is interacting with the dynamic.

Kay Jamison, in her 1999 Night Falls Fast, describes it this way:

We are, with the rest of life, periodic creatures, beholden for our rhythms to the rotations of the earth around the sun and the moon around the earth. The chemistry of our brains and bodies oscillates in adaptation to the earth's fluctuations in heat and light, and probably its electromagnetic fields as well. Like other mammals, our patterns of eating, sleeping, and other physical activities sway with the seasons, varying in accordance with changes in day length and temperature. A master biological clock, genetically determined, controls the cycling of our brain's constituent chemicals and shapes our responses to our physical environment.

On the diagnostic level, "up" points to "down" and "down" to "up." For instance, lucid intervals between depressions indicate recurrence, which suggests a close relationship to bipolar or bipolar waiting to happen. These recurrent downs may also imply the presence of "up," as depressed patients are scarcely in a position to recall their wacky wild times.

Likewise, "up" indicates that these depressions are likely to have different characteristics and follow a different course than so-called unipolar depressions.

Finally, cyclicity encourages clinicians to look for mixed states, ups and downs that bleed into each other - agitated depressions, dysphoric manias and hypomanias. These are far more common than once thought.

On a treatment level, clinicians need to be focusing on the cycle rather than simply the symptom du jour. An antidepressant to treat depression, for instance, may destabilize the cycle and induce mania.

On the recovery level, we are urged to think ahead and to anticipate and take an active role in the management of our illness. We take nothing for granted, not even "normal," as strictly speaking our well states are as much a part of our cycling and our illness as our ups and downs.

Perhaps most important, cycling encourages us to see our illness for what it really is: a series of recurring and often anomalous depressions broken up by ups that range from "normal" to floridly manic. On average, we spend far more of our time in depression than we do in mania or hypomania - by a ratio of three to one for those with bipolar I, according to a 2002 NIMH study. Estimates go much higher for those with bipolar II.

In this regard, "bipolar" is a blatant misnomer, as it implies equal parts "up" and "down," standing at attention at opposite ends, neither having anything to do with the other.